Image of pageindex.jpg

Image of replacement.jpg

If you're like most wheelchair users, you've likely heard of the Golden Rule when it comes to getting insurer funding for a new wheelchair, where the 5th anniversary of owning your existing wheelchair dictates your ability to have a new one funded by insurance.

Yet, if you've had a wheelchair for more than 5 years, you know that on your wheelchair's the 5th anniversary, nothing happened - no award certificate came in the mail, your provider didn't call, and a television crew with balloons and flowers didn't show up at your house, congratulating you on a new wheelchair.

In reality, like most golden rules, the 5-Year Golden Rule toward getting a new wheelchair funded isn't a golden rule at all.  Some wheelchair users have to wait more than 5 years for a new wheelchair, while others receive a new wheelchair in less than 5 years - most often regardless if insured by Medicare/Medicaid, the VA, or private insurance.   The funding of wheelchairs simply isn't tied to a calendar in the way that many wheelchair users believe.

While most insurers acknowledge that a wheelchair's lifespan should be equal to or greater than five years, it's not the literal age of a wheelchair that determines eligibility for replacement.  Toward actual funding, Medicare and most other insurers base a wheelchair's replacement on two explicit factors:  

1. Has the beneficiary's medical condition changed to a degree that he or she requires a new mobility product to best meet his or her needs?

Or:

2. Is the existing wheelchair is in such dire straits that it will cost less to replace it with a new wheelchair than to repair it?

If one of these circumstances is explicitly justifiable, in most cases, a user qualifies for a replacement wheelchair, with no regard of a 5-year time frame.

To illustrate how Medicare and most insurer funding operates independent of time frames, let's consider two sample cases:  

For the past 4 years, Mary, in her 50s, has had a progressive condition.  Mary used a cane for some time, but due to overall muscle weakness and fatigue, could no longer ambulate around her home.  As a result, 3 years ago, Medicaid funded a compact, light-rehab powerchair for Mary.  While the light-rehab powerchair initially served her well, Mary's condition, unfortunately, progressed quickly over the last 2 years, and she's now unable to shift her weight, reposition her legs, or maintain posture in her current powerchair, which isn't adaptable for rehab seating.  With her doctor, therapist, and provider documenting Mary's obvious needs, she's clearly eligible for a new wheelchair - most likely a tilt seating system - readily funded within only 3 years of receiving her existing wheelchair.

By contrast, Thomas, in his 30s and served by the same Medicaid system as Mary, has a static condition, where the affects of his disability haven't changed in the past 6 years since receiving his powerchair.  Fortunately, over the past 6 years, Thomas' powerchair has held up remarkable well, functioning with utmost reliability.  Yet, Thomas has his eye on a new wheelchair, having read all of the latest-greatest buzz on the WheelchairJunkie.com message board.  Unfortunately, even though Thomas' current powerchair is 6 years old, his static condition and well-serving powerchair make him ineligible for funding of a new powerchair.

While some wheelchair users may be frustrated by a funding system requiring extensive justification, it is a policy that at least strives toward some balance, where funding is prioritized for those most in need.  In this way, the next time you feel that your in need of a new wheelchair, look beyond the mythological 5-year mark, and assess if your medical condition has changed to such a degree that your existing wheelchair doesn't meet your needs, or if your current wheelchair is in such poor condition that replacement is more practical and cost-effective than repair.  Disability and wheelchairs don't follow a calendar and, in most cases, neither does insurance funding.

Published 6/06, Copyright 2006, WheelchairJunkie.com